Dissecting the Time Intervals for Admitted Patients

Emergency department managers and ED physicians evaluate their work processes by parameters that mark their use of diagnostic and treatment methods and lead to a quality disposition decision (discharge, admit, or transfer).

Graph 3 demonstrates that about one-third of the time in the ED is in the boarding process. In high volume EDs, that proportion of time is much higher. Inpatient boarding draws on ED resources using beds; nursing time; ED tech time; and needs for feeding, hydration, bathing, and addressing the needs of visitors.

Some hospitals delay decision time based on admitting team preferences and delays in placing an admission order due to processing needs. Some ED managers have reported that the definition of “decision time” has been changed in their facility, to make the “boarding time” length of time look shorter. This could be reflected in the data that are being reported for 2023 and 2024.

Boarding time begins the minute an admission decision is made by the ED physician or APP. This timestamp can be easily and consistently placed in the ED management system. But some hospitals prefer to define boarding as starting at a specific time interval—usually two or four hours—after the admission order. For accurate comparisons, boarding time starts at the decsion to admit. For optimal operations and patient care, boarding time should be short—the best-case scenario is for boarding to last no longer than 30 to 60 minutes.

Impact on Emergency Medicine Practice

Use the correct definitions and measures that allow ED staff to understand their process and how it compares with their peers.

The ED must have a prioritization system for those patients who are in most need of emergency medical care.

Make the ED as timely as possible in the door-to-decision process. Have new patients placed in areas of the ED that are well-designed for full patient assessment and a private interview. A complete patient assessment allows for the most rapid choice of diagnostics and treatment services. Patients with known vulnerabilities like children, seniors, those with mental health conditions, and those with impaired hearing or vision are particularly at risk for inadequate assessment and a poor choice of disposition.

The ED team cannot deliver high-quality and compassionate emergency care without engagement and leadership from the whole hospital. Effective patient flow and discharge pathways are needed out of the ED. The C-suite should be visible each day in the ED at its busiest times, allowing patient-based feedback to the hospital leaders about the care they are receiving, and the discomforts associated with care in hallways, a lack of privacy, and areas that do not allow for family interaction.